Risk management profile of etoricoxib: an example of personalized medicine

In Silico, In Vitro, and In Vivo Analysis of Tanshinone IIA and Cryptotanshinone from Salvia miltiorrhiza as Modulators of Cyclooxygenase-2/mPGES-1/Endothelial Prostaglandin EP3 Pathway

Tanshinone IIA (TIIA) and cryptotanshinone (CRY) from Salvia miltiorrhiza Bunge were investigated for their inhibitory activity against the cyclooxygenase-2 (COX-2)/microsomal prostaglandin E synthase-1 (mPGES-1)/endothelial prostaglandin 3 (EP3) pathway using in silico, in vitro, in vivo, and ex vivo assays. From the analysis of the docking poses, both diterpenoids were able to interact significantly with COX-2, 5-lipoxygenase (5-LO), platelet-activating factor receptor (PAFR), and mPGES-1. This evidence was further corroborated by data obtained from a cell-free assay, where CRY displayed a significant inhibitory potency against mPGES-1 (IC50 = 1.9 ± 0.4 µM) and 5-LO (IC50 = 7.1 µM), while TIIA showed no relevant inhibition of these targets. This was consistent with their activity to increase mice bleeding time (CRY: 2.44 ± 0.13 min, p ≤ 0.001; TIIA: 2.07 ± 0.17 min p ≤ 0.01) and with the capability to modulate mouse clot retraction (CRY: 0.048 ± 0.011 g, p ≤ 0.01; TIIA: 0.068 ± 0.009 g, p ≤ 0.05). For the first time, our results show that TIIA and, in particular, CRY are able to interact significantly with the key proteins involved not only in the onset of inflammation but also in platelet activity (and hyper-reactivity). Future preclinical and clinical investigations, together with this evidence, could provide the scientific basis to consider these compounds as an alternative therapeutic approach for thrombotic- and thromboembolic-based diseases.

Comparative cardiovascular safety of nonsteroidal anti-inflammatory drugs in patients with hypertension: a population-based cohort study

AIMS

Previous studies have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs) may be associated with higher cardiovascular risks. However, few have been active comparison studies that directly assessed the potential differential cardiovascular risk between NSAID classes or across individual NSAIDs. We compared the risk of major cardiovascular events between cyclooxygenase 2 (COX-2)-selective and nonselective NSAIDs in patients with hypertension.

METHODS

We conducted a cohort study of patients with hypertension who initiated COX-2-selective or nonselective NSAIDs in a population-based Taiwanese database. The outcomes included hospitalization for the following major cardiovascular events: ischaemic stroke, acute myocardial infarction, congestive heart failure, transient ischaemic attack, unstable angina or coronary revascularization. We followed patients for up to 4 weeks, based on the as-treated principle. We used inverse probability weighting to control for baseline and time-varying covariates, and estimated the on-treatment hazard ratios (HRs) and 95% conservative confidence interval (CIs).

RESULTS

We identified 2749 eligible COX-2-selective NSAID users and 52 880 eligible nonselective NSAID users. The HR of major cardiovascular events comparing COX-2-selective with nonselective NSAIDs after adjusting for baseline and time-varying covariates was 1.07 (95% CI 0.65, 1.74). We did not observe a differential risk when comparing celecoxib to diclofenac (HR 1.17; 95% CI 0.61, 2.25), ibuprofen (HR 1.36; 95% CI 0.58, 3.18) or naproxen (HR 0.75; 95% CI 0.23, 2.44). There was an increased risk with COX-2-selective NSAIDs, however, when comparing COX-2-selective NSAIDs with mefenamic acid (HR 2.11; 95% CI 1.09, 4.09).

CONCLUSIONS

Our results provide important information about the comparative cardiovascular safety of NSAIDs in patients with hypertension.

Lowering side effects of NSAID usage in osteoarthritis: recent attempts at minimizing dosage

INTRODUCTION

Osteoarthritis is a burdensome disease that causes progressive damage to articular cartilage. Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the preferred treatments for symptomatic relief. However, NSAIDs can cause serious dose-dependent side effects, which has prompted experts to recommend the minimization of NSAID dosage.

AREAS COVERED

This review focuses on three broad strategies that are currently being investigated or implemented to minimize NSAID dosage: nano-formulation, encapsulation, and topical delivery. The benefits, challenges and current status of these methods are discussed.

EXPERT OPINION

Multiple strategies are under investigation to lower NSAID dosage. There is great potential in developing formulations that utilize more than one of these strategies together. However, there are challenges to developing these lower dose preparations. In order to maximize the clinical potential of the abundance of NSAIDs that are both available and being developed, there is a major need for additional clinical studies directly comparing safety and efficacy of different preparations.

An Update of Microsomal Prostaglandin E Synthase-1 and PGE2 Receptors in Cardiovascular Health and Diseases

Nonsteroidal anti-inflammatory drugs (NSAIDs), especially cyclooxygenase-2 (COX-2) selective inhibitors, are among the most widely used drugs to treat pain and inflammation. However, clinical trials have revealed that these inhibitors predisposed patients to a significantly increased cardiovascular risk, consisting of thrombosis, hypertension, myocardial infarction, heart failure, and sudden cardiac death. Thus, microsomal prostaglandin E (PGE) synthase-1 (mPGES-1), the key terminal enzyme involved in the synthesis of inflammatory prostaglandin E2 (PGE2), and the four PGE2 receptors (EP1-4) have gained much attention as alternative targets for the development of novel analgesics. The cardiovascular consequences of targeting mPGES-1 and the PGE2 receptors are substantially studied. Inhibition of mPGES-1 has displayed a relatively innocuous or preferable cardiovascular profile. The modulation of the four EP receptors in cardiovascular system is diversely reported as well. In this review, we highlight the most recent advances from our and other studies on the regulation of PGE2, particularly mPGES-1 and the four PGE2 receptors, in cardiovascular function, with a particular emphasis on blood pressure regulation, atherosclerosis, thrombosis, and myocardial infarction. This might lead to new avenues to improve cardiovascular disease management strategies and to seek optimized anti-inflammatory therapeutic options.

Evolution to low-dose NSAID therapy

All NSAIDs are to varying degrees associated with gastrointestinal, cardiovascular and renal adverse effects (AEs). Differences in selectivity for inhibition of the COX isozymes (COX-1/COX-2) have been used as an indicator of the likelihood of experiencing an AE, but the measure of 'selectivity' commonly used is less than desirable, and selectivity has not yielded unequivocal superior safety. Recent guidelines recommend that NSAIDs be used at the lowest effective dose and for the shortest period of time. In response, 'low-dose' NSAID formulations have been developed. Such formulations may help by reducing overall systemic exposure, thereby reducing the frequency or severity of AEs. It seems timely to review the need, rationale and application of such an approach.

Molecular basis for nonspecificity of nonsteroidal anti-inflammatory drugs (NSAIDs)

Inhibition of the production of inflammatory mediators by the action of nonsteroidal anti-inflammatory drugs (NSAIDs) is highly accredited to their recognition of cyclooxygenase enzymes. Along with inflammation relief, however, NSAIDs also cause adverse effects. Although NSAIDs strongly inhibit enzymes of the prostaglandin synthesis pathways, several other proteins also serve as fairly potent targets for these drugs. Based on their recognition pattern, these receptors are categorised as enzymes modifying NSAIDs, noncatalytic proteins binding to NSAIDs and enzymes with catalytic functions that are inhibited by NSAIDs. The extensive binding of NSAIDs is responsible for their limited in vivo efficacy as well as the large spectrum of their effects. The biochemical nature of drugs binding to multiple protein targets and its implications on physiology are discussed.

Current perspectives in NSAID-induced gastropathy

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most highly prescribed drugs in the world. Their analgesic, anti-inflammatory, and antipyretic actions may be beneficial; however, they are associated with severe side effects including gastrointestinal injury and peptic ulceration. Though several approaches for limiting these side effects have been adopted, like the use of COX-2 specific drugs, comedication of acid suppressants like proton pump inhibitors and prostaglandin analogs, these alternatives have limitations in terms of efficacy and side effects. In this paper, the mechanism of action of NSAIDs and their critical gastrointestinal complications have been reviewed. This paper also provides the information on different preventive measures prescribed to minimize such adverse effects and analyses the new suggested strategies for development of novel drugs to maintain the anti-inflammatory functions of NSAIDs along with effective gastrointestinal protection.

Coxibs: pharmacology, toxicity and efficacy in cancer clinical trials

This chapter briefly summarizes the current knowledge about the role of nonsteroidal anti-inflammatory drugs (NSAIDs), specially focusing on those selective for cyclooxygenase (COX)-2 (coxibs), on colorectal cancer (CRC) onset, and progression. Both epidemiological and experimental studies have reported that these drugs reduce the risk of developing colonic tumors. However, the promising use of coxibs in chemoprevention was halted abruptly due to the detection on enhanced cardiovascular (CV) risks. Thus, we discuss the clinical data and plausible mechanisms of CV hazards associated with traditional NSAIDs and coxibs. The extent of inhibition of COX-2-dependent prostacyclin, an important vasoprotective and anti-thrombotic pathway, in the absence of a complete suppression of COX-1-dependent platelet function, at common doses of NSAIDs, might play a role in CV toxicity. Coxibs might still be reserved for younger patients with familial adenomatous polyposis (FAP). However, it should be taken into consideration that recent findings of enhanced thromboxane (TX)A(2) biosynthesis in colon tumorigenesis, detected in humans. In this context, the use of low-dose aspirin (which mainly acts by inhibiting platelet COX-1-dependent TXA(2)) may have a place for chemoprevention of CRCs (see also Chap. 3 ). The possible use of coxibs to prevent CRC will depend mainly on research progresses in biomarkers able to identify the patients uniquely susceptible to developing thrombotic events by inhibition of COX-2.

Managing the adverse effects of nonsteroidal anti-inflammatory drugs

Conventional medical treatment for rheumatoid arthritis and osteoarthritis includes the use of NSAIDs (traditional and selective inhibitors of cyclooxygenase [COX]-2), because they provide unmistakable and significant health benefits in the treatment of pain and inflammation. However, they are associated with an increased risk of serious gastrointestinal (GI) and cardiovascular (CV) adverse events. Both beneficial and adverse effects are due to the same mechanism of action, which is inhibition of COX-dependent prostanoids. Since CV and GI risk are related to drug exposure, a reduction in the administered dose is recommended. However, this strategy will not eliminate the hazard owing to a possible contribution of individual genetic background. Further studies will be necessary to develop genetic and/or biochemical markers predictive of the CV and GI risk of NSAIDs.

Musculoskeletal pain: prescription of NSAID and weak opioid by primary health care physicians in Sweden 2004-2008 - a retrospective patient record review

Purpose:

To study the prescription of oral analgesics for musculoskeletal pain by primary care physicians over a 5-year period in Sweden.

Design:

A retrospective automatic database review of patient records at four primary health care centers. All prescriptions of NSAIDs, weak opioids, and coprescriptions of gastroprotecting medications to patients with musculoskeletal were retrieved for the period January 1, 2004 to November 11, 2008.

Results:

A total of 27,067 prescriptions prescribed to 23,457 patients with musculoskeletal pain were analyzed. Of all prescriptions, NSAIDs were the most commonly prescribed analgesic comprising 79%, tramadol was the second most commonly prescribed analgesic comprising 9%, codeine the third most (7%), and dextropropoxyphene the fourth (5%). The proportion of NSAIDs and weak opioids and the proportion of the different weak opioids prescribed showed no change over time. The proportion of nonselective and selective NSAIDs prescribed changed; Coxib prescriptions decreased from 9% to 4% of all analgesics prescribed in 2004–2007 with no change in 2008.

Conclusion:

NSAIDs were found to be the dominant class of analgesic prescribed by primary care physicians to patients diagnosed as musculoskeletal pain. No change was observed in the proportion of NSAID and weak opioid prescription over the period studied. Prescription of selective Coxibs decreased and was less than 4% in 2008. The impact on gastrointestinal and cardiovascular adverse effects associated with the extensive prescription of NSAIDS for musculoskeletal pain warrants further analysis.